Urgent Care Emergencies E-Book
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- Herausgeber: John Wiley & Sons
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- Sprache: Englisch
Newly updated reference highlighting high-risk aspects of common, seemingly minor medical illnesses and injuries
Urgent Care Emergencies is a concise, quick reference designed to help healthcare professionals avoid pitfalls in challenging and fast-paced clinical settings. This text focuses on caring for patients with seemingly minor acute illnesses and injuries that may carry substantial morbidity if not appropriately recognized and managed. The text covers a wide range of emergencies that may be encountered in urgent care centers, clinics, or other acute care settings. It focuses on the most commonly encountered complaints and conditions, including genitourinary issues, common infections, orthopedic injuries, wounds, back pain, head and neck problems, and skin complaints. This new edition also includes additional chapters on the importance of effective patient communication, pharmacologic pitfalls, special issues in the care of pediatric and geriatric patients, and a special chapter focused on legal pitfalls.
As healthcare continues to evolve, this Second Edition serves as an essential resource for clinicians in urgent care and emergency departments. Each chapter is authored by experienced acute care clinicians and includes clinical wisdom that readers can apply directly to the care of their own patients.
Written by a team of highly qualified authors, Urgent Care Emergencies stresses important topics such as
- Seemingly minor orthopedic injuries with a high risk for limb-threatening vascular injury
- The limitations of radiographic imaging in the evaluation of subarachnoid hemorrhage
- The potential life-threatening complications of local anesthetics
- The importance of considering necrotizing fasciitis or Fourniere gangrene in seemingly minor soft tissue infections
- Red flags in pediatric back pain
- Key factors in evaluating sore throat to prevent morbidity and speed resolution
This updated edition of Urgent Care Emergencies is an essential at-your-fingertips reference for any physician, advanced practice provider, and other medical professional working in a setting that manages acute unscheduled medical concerns.
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Veröffentlichungsjahr: 2024
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Table of Contents
Cover
Table of Contents
Title Page
Copyright Page
List of Contributors
Preface to the Second Edition
CHAPTER 1: HEENT Pitfalls
Introduction
Eye
Throat
Ear
Nose
Foreign bodies
References
CHAPTER 2: Management of Genitourinary Complaints
Introduction
References
CHAPTER 3: Orthopedic Pitfalls of the Upper Extremity
Introduction
Conditions predisposing to long‐term disability
References
CHAPTER 4: Orthopedic Pitfalls of the Lower Extremity
Introduction
References
CHAPTER 5: Orthopedic Pitfalls: Pediatrics
Introduction
References
CHAPTER 6: Pitfalls of Wound Management
Introduction
Wound preparation
Foreign bodies
Plantar wounds
Wound care instructions
Zipper injuries
Burn management
References
CHAPTER 7: Emergency Dermatology for the Acute Care Provider
Introduction
Dermatologic emergencies
Necrotizing soft tissue infections
Urticaria
Common infectious rashes
Treating skin problems
Summary
References
CHAPTER 8: Management of Common Infections
Introduction
Antibiotic therapy
References
CHAPTER 9: Headache
Introduction
References
CHAPTER 10: The Evaluation and Management of Back Pain
Introduction
Pediatric back pain
Evaluation
Treatment
Specific disease processes
References
CHAPTER 11: Pediatric Pitfalls
Introduction
Febrile infants
References
CHAPTER 12: Geriatric Pitfalls
Introduction
Peptic ulcer disease
Biliary tract disease
Appendicitis
Mesenteric ischemia
Ruptured abdominal aortic aneurysm
Urinary tract infections
Central nervous system injuries
Fractures
Conclusion
References
CHAPTER 13: Pharmacology Pitfalls and Pearls in Urgent Care Medicine
Introduction
Pitfalls and pearls in pharmacology of commonly used medications
Important adverse reactions
Metabolism
Medications with a narrow therapeutic index
Pitfalls in special populations
References
CHAPTER 14: Talking the Talk
Introduction
References
CHAPTER 15: Medical Malpractice in Urgent Care
The case
The discussion
Medical malpractice risk
The three levels of a chief complaint
Picking the low‐hanging fruit
Bringing it all home
Conclusion
References
Index
End User License Agreement
List of Tables
Chapter 1
Table 1.1 Treatment of conjunctivitis, corneal abrasions, ulcers, and foreig...
Table 1.2 Modified Centor criteria.
Table 1.3 Application of modified Centor criteria [17, 18].
Table 1.4 Treatment choices for Group A strep pharyngitis.
Table 1.5 Treatment considerations for acute otitis media.
Table 1.6 Treatment options for acute otitis media.
Chapter 5
Table 5.1 Salter–Harris classification of pediatric fractures.
Chapter 7
Table 7.1 Oral antihistamines for urticaria.
Table 7.2 Treatment of uncomplicated zoster.
Table 7.3 Topical corticosteroids.
Table 7.4 Estimating the necessary amount of topical corticosteroid for adul...
Chapter 8
Table 8.1 Recommended initial treatment of skin and soft tissue infections (...
Table 8.2 Infectious Diseases Society of America oral antibiotic recommendat...
Table 8.3 Antimicrobial agents and dosing for outpatient management of CA‐MR...
Table 8.4 Antimicrobial agents and dosing for outpatient management of uncom...
Chapter 11
Table 11.1 Decision rule for identifying children at low risk for clinically...
Chapter 12
Table 12.1 Most common symptoms that manifest as atypical presentations of a...
Chapter 13
Table 13.1 Opioid analgesic dosing.
Table 13.2 Local anesthetics.
Table 13.3 Drugs with a narrow therapeutic index.
Chapter 14
Table 14.1 Clinical conditions and low‐yield interventions that patients may...
List of Illustrations
Chapter 3
Figure 3.1 Axillary view demonstrating a posterior dislocation.
Figure 3.2 AP view showing signs of posterior shoulder dislocation.
Figure 3.3 The anatomic snuffbox (ASB). The ASB is the depression formed by ...
Figure 3.4 Fight bite. This patient presented 12 hours after a clenched‐fist...
Figure 3.5 Modified Elson test. (a) The modified Elson test is performed by ...
Figure 3.6 Flexor digitorum profundus (FDP) test. To isolate the flexion of ...
Figure 3.7 Fracture associated with mallet finger.
Chapter 4
Figure 4.1 Insall‐Salvati ratio suggesting a patellar tendon rupture. LT, pa...
Figure 4.2 Ultrasound evaluation demonstrating patellar tendon rupture.
Figure 4.3 Anatomy of the nerves of the lateral lower extremity, demonstrati...
Figure 4.4 Revealing a double fluid sign (arrow) consistent with a lipohemar...
Figure 4.5 Radiographic assessment of a syndesmotic ankle injury as seen on ...
Figure 4.6 Anatomy of the Lisfranc ligament and description of injury.
Figure 4.7 A left foot Lisfranc injury, defined by the medial border of the ...
Figure 4.8 The watershed vascular supply at the base of the fifth metatarsal...
Chapter 5
Figure 5.1 Salter–Harris type 1 fracture of the distal radius in a nine‐year...
Figure 5.2 Anteroposterior (AP) and lateral forearm of a radial buckle fract...
Figure 5.3 Hyperpronation method of nursemaid’s elbow reduction. With the ch...
Figure 5.4 (a) Anteroposterior and (b) lateral radiographs of a normal right...
Figure 5.5 Lateral elbow radiograph at four years of age. Note the posterior...
Figure 5.6 Anteroposterior radiograph of tibia/fibula in a two‐year‐old male...
Figure 5.7 (a) Anteroposterior and (b) frog‐leg lateral radiographs of the h...
Figure 5.8 Three examples of commonly missed apophyseal avulsion injuries. (...
Figure 5.9 Anteroposterior view of left femur and oblique chest radiographs ...
Chapter 6
Figure 6.1 Cut below the entrapped skin (asterisk) and pull the teeth of the...
Figure 6.2 Anatomy of a zipper's sliding mechanism.
Chapter 7
Figure 7.1 Approach to the patient who presents with a rash. AMS, altered me...
Chapter 8
Figure 8.1 Steps in loop drain for treatment of large abscesses.
Chapter 10
Figure 10.1 Schober's measurement. Place a mark 10 cm above and 5 cm below t...
Chapter 12
Figure 12.1 Inferior ST‐elevation myocardial infarction in an elderly patien...
Figure 12.2 Free intraperitoneal air in a patient with a perforated gastric ...
Figure 12.3 A dilated appendix that is not filling with oral contrast, consi...
Figure 12.4 Right subdural hematoma with midline shift in an elderly patient...
Guide
Cover Page
Table of Contents
Title Page
Copyright Page
List of Contributors
Preface to the Second Edition
Begin Reading
Index
WILEY END USER LICENSE AGREEMENT
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Urgent Care Emergencies
Avoiding the Pitfalls and Improving the Outcomes
SECOND EDITION
EDITED BY
Deepi G. Goyal
Mayo ClinicRochester, MN, USA
Amal Mattu
University of Maryland School of MedicineEdgewater, MD, USA
This second edition first published 2025© 2025 John Wiley & Sons Ltd
Edition HistoryJohn Wiley & Sons, Ltd (1e, 2012)
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List of Contributors
Michael K. Abraham, MDDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Jana L. Anderson, MDDepartment of Emergency Medicine and PediatricsMayo ClinicRochester, MN, USA
Elizabeth Bermudez, MDDepartment of Emergency MedicineMayo Clinic Southeast Minnesota Health System andMayo Clinic RochesterRochester, MN, USA
Michael C. Bond, MDDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Laura J. Bontempo, MD, MEdDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Emily Catalano, MD, CAQSMDepartment of Emergency MedicineEast Carolina UniversityGreenville, NC, USA
Daniel Chiang, MDDepartment of Emergency MedicineMayo Clinic Southeast Minnesota Health System andMayo Clinic RochesterRochester, MN, USA
Kristi Colbenson, MC, CAQSMDepartment of Sports MedicineMayo ClinicRochester, MN, USADepartment of Emergency Medicine, Mayo ClinicRochester, MN, USA
Jennifer Hicks, DODepartment of Family MedicineAdena Health SystemChillicothe, OH, USA
James L. Homme, MDDepartment of Emergency Medicine and PediatricsMayo ClinicRochester, MN, USA
Kirstin Kooda, PharmD, BCPS, BCCCPDepartment of PharmacyMayo ClinicRochester, MN, USA
Phillip D. Magidson, MDDepartment of Emergency Medicine andDivision of Geriatric Medicine and GerontologyJohns Hopkins School of MedicineBaltimore, MD, USA
Joseph P. Martinez, MDDepartment of Emergency Medicine andDepartment of MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Sarayna S. McGuire, MDDepartment of Emergency MedicineMayo ClinicRochester, MN, USA
Gabriella M. Miller, MDDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Siamak Moayedi, MDDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Bennett A. Myers, MDDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Neha P. Raukar, MD, MS, CAQSMDepartment of Emergency MedicineMayo ClinicRochester, MN, USA
Stephen M. Schenkel, MDDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Sarah K. Sommerkamp, MDDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Ryan Spangler, MDDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Mercedes Torres, MDDepartment of Emergency MedicineUniversity of Maryland School of MedicineBaltimore, MD, USA
Laura Walker, MD, MBADepartment of Emergency MedicineMayo ClinicRochester, MN, USA
Michael B. Weinstock, MDDepartment of Emergency MedicineAdena Health SystemChillicothe, OH, USADepartment of Emergency MedicineThe Wexner Medical Center atThe Ohio State UniversityColumbus, OH, USA
George Willis, MDDepartment of Emergency MedicineJoe R. and Teresa Lozano Long School of MedicineUniversity of Texas Health San AntonioSan Antonio, TX, USA
Preface to the Second Edition
Injuries and illnesses are unpredictable. Affected patients want and deserve timely and effective care.
In the decade since the publication of the first edition of Urgent Care Emergencies: Avoiding the Pitfalls and Improving the Outcomes, the healthcare landscape has continued to evolve dramatically, with the surging demand for alternative venues to address unscheduled injuries and medical conditions. Healthcare systems remain stressed with rising patient volumes, staffing instability, and increasing cost constraints. As traditional emergency departments and primary care offices are overwhelmed, walk‐in clinics, urgent care, and express care centers have emerged as vital components of the healthcare system to allow patients timely access for lower‐acuity conditions.
Since the original publication in 2012 there has been substantial growth of urgent care centers and similar facilities. According to the Urgent Care Association, the number of urgent care centers in the United States has increased by over 50% in the past decade, with more than 14,000 centers now in operation. This expansion reflects the increasing reliance on these facilities to provide accessible, efficient care for noncritical conditions. The role of urgent care centers in alleviating the burden on emergency departments and improving patient outcomes is more critical now than ever.
Because most patients coming to these settings have low‐acuity presentations and diagnoses, providers must be even more vigilant to avoid errors that may lead to poor outcomes and simultaneously identify high‐risk diagnoses that should be expeditiously referred to other settings.
This second edition of Urgent Care Emergencies seeks to address the challenges faced by healthcare providers in these dynamic environments. It underscores the importance of timely and accurate diagnosis and treatment of seemingly minor injuries and illnesses to avoid serious morbidity. The text aims to highlight both common pitfalls in the management of low‐acuity conditions and high‐risk diagnoses that must be excluded. This edition includes a chapter addressing medical malpractice, especially as it pertains to medical practice in the United States.
All chapters in this edition have been completely updated to reflect the latest clinical guidelines and best practices. The chapter authors were selected for their expertise in their respective fields, ensuring that the content is both authoritative and relevant. At the end of each chapter readers will find valuable pearls of wisdom aimed at enhancing patient care and outcomes.
While the title suggests that this book is aimed at providers in urgent care settings, it is meant to serve as a valuable resource for any healthcare provider who evaluates low‐acuity complaints, whether in an emergency department, urgent care center, clinic, or other healthcare setting. It is not designed to be comprehensive but is meant to be practical, suitable for cover‐to‐cover reading or as a reference during daily practice. We hope that this updated edition will continue to support healthcare professionals in delivering the highest‐quality care to their patients.
Deepi G. Goyal Rochester, MNAmal Mattu Edgewater, MD
CHAPTER 1HEENT Pitfalls
Laura J. Bontempo and Sarah K. Sommerkamp
Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
Introduction
Emergencies affecting the head, eyes, ears, nose, and throat (HEENT) constitute a large component of chief complaints seen in urgent care centers. The majority of these patients have benign conditions that can be managed on an outpatient basis. However, some seemingly innocuous complaints can portend more serious diseases that pose a significant risk of morbidity and possibly mortality. As with most diseases, the key to differentiating between minor and dangerous conditions is the history and physical examination. A huge spectrum of pathology can manifest in the head and neck. In this chapter we present key facts, highlight pitfalls in diagnosing these conditions, and offer pearls intended to facilitate their management.
Eye
Pitfall | Failure to identify red flag symptoms leads to inappropriate or unrecognized need to transfer patients requiring emergency evaluation
A wide variety of eye complaints are encountered by urgent care providers. Identifying the emergent conditions that require emergency department (ED) or emergent ophthalmologic care is crucial. Red flags include a severely painful red eye, acute vision loss, anisocoria, and photophobia [1]. An acute red eye may represent acute angle glaucoma, endophthalmitis, uveitis, or keratitis. Visual acuity should be documented on these patients. Acute monocular visual loss may signify another dangerous condition, such as central retinal artery occlusion, central retinal vein occlusion, retinal detachment, or a central nervous system process (stroke, transient ischemic attack [TIA], or multiple sclerosis). Patients with concern for these diagnoses should be referred to an ED or for emergent ophthalmologic follow‐up. After identifying which patients need a higher level of care, there are still many eye conditions that can effectively be cared for in the urgent care setting.
Corneal abrasion, ulcers, and foreign bodies
Differentiation between corneal abrasions, corneal ulcers, and corneal foreign bodies (FBs) can be difficult. The majority of patients with any of these conditions present with eye pain and a gritty or FB sensation. Patients with suspected corneal epithelial defects should have a full eye examination. Use of a slit lamp is preferred to the Wood's lamp. The instillation of analgesic and/or cycloplegic drops will significantly relieve the patient's symptoms and increase their ability to tolerate the examination, but these drops should not be used if globe rupture is suspected. Globe rupture can occur after trauma or a penetrating FB and should be suspected if there is buckling of the sclera or if there appears to be fluid draining from the orbit. This is a true ophthalmologic emergency, and no pressure or foreign material should be introduced into the eye of this patient. Fluorescein staining is mandatory for the evaluation of a corneal defect and to assess for ulcers or dendritic lesions seen with herpes simplex virus (HSV) keratitis. Varicella zoster virus (VZV) should be suspected in patients with a vesicular rash on the forehead or nose and should be referred to ophthalmology [2]. In patients with herpes virus infection concerns (HSV or VZV), steroids should only be used if directed by ophthalmology. Defects in the epithelial surface appear as a stain that does not clear with blinking. The size and position of any defect(s) should be documented. Punctate defects, which appear in a circular pattern, are sometimes seen in contact lens wearers, particularly after prolonged wear. Larger defects with a crater formation are ulcers.
Table 1.1 Treatment of conjunctivitis, corneal abrasions, ulcers, and foreign bodies [3–6].
Indication
Contact lenses
Antibiotic
Dose
Duration of therapy
Abrasion or FB
No
Trimethoprim/polymyxin B
1–2 drops q 3 h
Continue until symptom free for >24 h
Conjunctivitis
No
Trimethoprim/polymyxin B
1 drop q 6 h
5–7 d
Abrasion or conjunctivitis Not from FB
No
Erythromycin
Ointment 0.5″ q 2–4 h
Continue until symptom free for >24 h/5–7 d
Abrasion or FB
Yes
Ciprofloxacin
Day 1–2: q 2 h when awake; days 3–7: q 4 h
Until evaluation by ophthalmologist
Conjunctivitis
Yes
Ciprofloxacin
1–2 drops q 6 h
5–7 d
Abrasion or FB
Yes
Moxifloxacin
1 drop q 6–8 h
Until evaluation by ophthalmologist
Conjunctivitis
Yes
Moxifloxacin
1 drop q 6–8 h
7 d
Ulcer
NA
Moxifloxacin
1–2 drops q 1 h
Until evaluation by ophthalmologist
VZV
NA
Antiviral: acyclovir or ganciclovir
IV/oral/topical
Ophthalmologist evaluation needed
FB, foreign body; IV, intravenous; NA, not applicable; q, every; VZV, varicella zoster virus.
Parallel vertical abrasions should raise suspicion for an FB under the lid. When this type of injury is detected, the patient's eyelid should be everted to allow further assessment. Without treatment, and over time, the vertical abrasions will coalesce and form an ulcer. An FB may be superficially lodged directly on the corneal surface. In many cases FBs can be removed with a cotton swab or by irrigation, but if that procedure is unsuccessful, removal with a needle or burr may be necessary and should be done only by someone with specific training. Metal FBs may lead to the development of a rust ring, which should be removed by an ophthalmologist [3]. Emergent ophthalmologic consultation is indicated for globe rupture or intraocular foreign body. Following removal of the superficial FB, patients should be treated with antibiotic drops (not ointment) as per Table 1.1. An FB consisting of vegetation should be treated with a fluoroquinolone [4]. Perforating or intraocular FBs will require systemic antibiotics and transfer [3].
KEY FACT | Patients with corneal abrasions, ulcers, and corneal foreign bodies should all be treated with antibiotics.
The immediate treatment of corneal abrasions, ulcers, and FBs is similar (Table 1.1). Simple abrasions that are smaller than 3 mm do not require follow‐up as long as an FB is not present, the patient's visual acuity is normal, and symptoms resolve within 24 hours [7]. However, if there is any doubt, referral to an ophthalmologist is reasonable. All other defects should be seen by an ophthalmologist within 24 hours. Antibiotics, which may be prescribed as either ointment or drops, should be administered to all patients with epithelial defects. Ointment is generally preferred (particularly for children) because it stays in place longer and lubricates the eye. However, ointments are not well tolerated by most adults because they obscure vision. Contact lens wearers with corneal abrasions require antipseudomonal antibiotic coverage and should be advised to refrain from wearing their contact lenses until they are cleared to do so by an ophthalmologist. All patients with corneal ulcers also require antipseudomonal antibiotic coverage.
Patients with painful corneal abrasions may require systemic analgesia. Ophthalmic nonsteroidal anti‐inflammatory drugs (NSAIDs) may be prescribed but are expensive. Topical anesthetics such as tetracaine when used for the first 24 hours have been shown to improve analgesia, but should be used with caution as repeated use may be associated with the development of ulcers [8]. Eye patching has not been shown to be effective in accelerating healing. In fact, because it might worsen the infection and thus lengthen the time to recovery, patching is not recommended [9].
Conjunctivitis
Commonly known as “pink eye,” conjunctivitis presents with an irritated, erythematous conjunctiva with discharge. Visual acuity should be minimally affected, if at all. The etiology may be infectious or noninfectious (allergic/chemical). Infectious causes are most commonly bacterial or viral, and it may be difficult to differentiate between the two. Generally, a thin watery discharge from the eye accompanied by symptoms of an upper respiratory infection is more likely to be viral in etiology. This pathology is self‐limiting and patients do not require treatment with antibiotics. Symptom relief with cool compresses, artificial tears, and anticipatory guidance regarding duration of symptoms and handwashing are paramount to good patient care. Purulent drainage is more commonly caused by a bacterial source [10]. While bacterial conjunctivitis may improve on its own, topical antibiotics are recommended. Topical antibiotics typically shorten the duration of illness and decrease the amount of time out of work/school. Patients who wear contact lenses need to be treated with antipseudomonal antibiotics (see Table 1.1). Hyperpurulent discharge, frequently seen in neonates, immunocompromised patients, or patients with a history of sexually transmitted infection, is most concerning for gonococcal or chlamydia conjunctivitis, which requires systemic antibiotics. Testing/culture should be completed on these patients. Allergic conjunctivitis presents with mild erythema and itching as a primary concern. It can be treated with topical antihistamines or mast‐cell stabilizers. Conjunctivitis rarely causes severe eye pain, constant visual loss, or photophobia. If these symptoms occur, consider an alternative diagnosis.
KEY FACT | All patients with corneal ulcers require antipseudomonal antibiotic coverage.
Hyphema versus subconjunctival hematoma
A hyphema is a collection of blood in the anterior chamber commonly occurring from trauma. Patients typically present with eye pain and pupillary constriction. Visual acuity is variably affected, based on the amount of blood present.
Patients who should receive emergent consultation and strong consideration of admission include those with sickle cell disease, bleeding dyscrasias (such as anticoagulant use or hemophilia), potential open globe injuries, elevated intraocular pressure (IOP), or hyphemas that fill ≥50% of the anterior chamber [6]. Healthy patients with none of the above risk factors can be discharged home with ophthalmologic follow‐up within 12–24 hours. Patients should elevate their head and avoid bright lights. A rigid shield is sometimes used to avoid any further trauma. NSAIDs should be avoided because of their associated bleeding risk. Nausea and vomiting should be treated aggressively since they can raise IOP. These instructions should be clearly communicated to any patient being discharged. Patients suspected to be unreliable and those unable to return if their condition worsens should be observed or admitted.
Subconjunctival hematomas occur where there is blood that has extravasated from the conjunctival or episcleral vessels into the subconjunctival space. Subconjunctival hematomas are typically painless. They may occur after minor trauma or be atraumatic. They are more common in older individuals who have more fragile vessels (patients with diabetes, hypertension, hyperlipidemia, etc.) [11]. The appearance of subconjunctival hemorrhage can be dramatic and very concerning to the patient, but fortunately the vast majority of these cases are benign and need no labs, imaging or treatment. Patients should be advised not to wear contact lenses until symptoms resolve [11].
Pitfall | Failure to identify the location of the blood can lead to confusion between a subconjunctival hemorrhage (seen laterally in the sclera) and a hyphema (seen in the lower portion of the iris), which have different treatments and follow‐up needs
Pre‐septal versus septal cellulitis
Patients with pre‐septal or septal (orbital) cellulitis will frequently present stating that they have “eye pain.” Differentiation between these two processes is crucial as septal cellulitis is potentially vision threatening. Pre‐septal cellulitis is more commonly encountered in pediatric patients, though it does occur in adults as well. It involves the eyelid and anterior structures of the eye. It is more common and milder than orbital cellulitis, which affects the tissues inside the orbit. Orbital cellulitis can be vision and even life threatening. Both conditions can present with red swollen skin around the eye. The exam findings that raise concern for septal cellulitis are pain with extraocular movement, ophthalmoplegia, and proptosis. Frequently a history of recent bacterial rhinosinusitis is described. If the diagnosis is uncertain, computed tomography (CT) should be completed [12]. Orbital cellulitis should be treated with intravenous (IV) vancomycin and a cephalosporin. These patients should be referred to the ED for hospitalization. Pre‐septal cellulitis may at times require hospitalization in patients under age one year, those who have failed outpatient antibiotics, or those who are toxic in appearance, but most patients can be treated as outpatients. Antibiotic coverage should include coverage for methicillin‐resistant Staphylococcus aureus (MRSA) with trimethoprim‐sulfamethoxazole or clindamycin, plus a beta‐lactam such as amoxicillin‐clavulanate or a cephalosporin.
KEY FACT | Assessment of extraocular movements and evaluation for ophthalmoplegia and proptosis is essential in evaluating patients for orbital cellulitis. Failure to identify orbital cellulitis can be vision and life threatening.
Throat
Sore throat is an extremely common complaint and has a broad differential diagnosis, ranging from viral illness to life‐threatening conditions such as epiglottis and retropharyngeal abscess. In the majority of cases these conditions can be differentiated by history and physical examination.
KEY FACT | Difficulty breathing, inability to swallow secretions, resistance/inability to lie flat, painful neck range of motion, and/or head held forward in the sniffing position are all indications of more serious pathology and warrant further investigation.
Bacterial versus viral pharyngitis
Concern for “strep throat” brings many people to acute care centers. Group A Streptococcus (GAS), however, accounts for only 5–15% of pharyngitis in adults and 15–35% in children [13]. Other common bacterial causes of acute pharyngitis include gonorrhea, diphtheria, and Fusobacterium. Viruses account for the majority of cases of pharyngitis.
The diagnosis of GAS involves a combination of clinical decision tools and testing. Patients with GAS pharyngitis are generally between 3 and 44 years old; have a fever, tonsillar exudates, and anterior cervical lymphadenopathy; and are without a cough. The modified Centor criteria are used to guide testing and treatment (Table 1.2) [14].
KEY FACT | Viruses account for the majority of cases of pharyngitis. Group A Streptococcus is responsible for up to 15% of cases in adults and 35% of cases in children.
Polymerase chain reaction (PCR) testing and culture are often impractical in an urgent care practice given that it can take several days to get results. Alternatively, a point‐of‐care rapid antigen detection test (RADT) can be used. RADTs are approximately 85% sensitive and 96% specific, although there is significant variability of these values in different investigations [13]. A positive test result is helpful, but a negative result does not rule out the disease. To perform this test, vigorously swab both tonsils and the posterior pharynx. Obtaining an adequate sample is crucial, as sensitivities correlate directly to inoculum size [14].
Treatment
Treatment of GAS pharyngitis with antibiotics can reduce the duration of illness by 1–2 days, decrease the duration of communicability, and reduce the risk of suppurative complications (peritonsillar abscess, sinusitis, retropharyngeal abscess) and rheumatic fever. Antibiotics will not reduce the risk of acute glomerulonephritis [15].
Table 1.2 Modified Centor criteria.
Category
Criteria
Points
Age
3–14 years
1
15–44 years
0
≥45 years
−1
Tonsillar exudates
Present
1
Tender/swollen anterior cervical lymph nodes
Present
1
Temp >38 °C (100.4 °F)
Present
1
Cough
Absent
1
Overprescribing of antibiotics has both personal (Clostridium difficile) and population (antibiotic resistance) risks. In the United States antimicrobial resistance leads to 48,000 deaths annually, underscoring the need to follow treatment guidelines when deciding to prescribe antibiotics for pharyngitis [16]. The decision as to whether or not to prescribe antibiotics can be guided by the patient's modified Centor criteria score (Table 1.3). Antibiotic choices are listed in Table 1.4.
KEY FACT | The diagnosis of group A strep pharyngitis is made through a combination of clinical suspicion, clinical decision tools, and testing.
Table 1.3 Application of modified Centor criteria [17, 18].
Score
Probability of GAS (%)
Recommendation
0–1
<10
No further testing; no antibiotics
2
11–17
RADT and/or culture; antibiotics only if positive
3
28–35
RADT and/or culture; antibiotics only if positive
4–5
51–53
RADT and/or culture; antibiotics if positive or if no testing is available
GAS, Group A Streptococcus; RADT, rapid antigen detection test.
Table 1.4 Treatment choices for Group A strep pharyngitis.
Antibiotic
Dose
Duration
Benzathine G penicillin
1.2 million units IM once If ≤27 kg: 600 K units IM
Once
PenVK
500 mg PO q 12 h If ≤27 kg: 250 mg PO q 12 h
10 days
If penicillin allergic (choose one)
Clindamycin
300 mg PO q 8 h Peds: 7 mg/kg (max 300 mg) q 8 h
10 days
Cephalexin
500 mg PO q 12 h Peds: 20 mg/kg (max 500 mg) q 12 h
10 days
IM, intramuscularly; Peds, pediatrics; PO, orally; q, every.
Adjunctive treatment for pharyngitis (bacterial and viral) includes hydration, fever control, and, in most cases, corticosteroids. Corticosteroids improve severe throat pain and shorten the duration of symptoms [19]. Dexamethasone, 10 mg IV or orally in adults (0.6 mg/kg, max 10 mg in children), can be given as a one‐time dose. Acetaminophen and/or NSAIDs may be used for fever and analgesia.
KEY FACT | Corticosteroids improve severe throat pain and shorten the duration of symptoms for most bacterial and viral pharyngitis.
Mononucleosis
Mononucleosis deserves special consideration for any patient with pharyngitis, particularly if antibiotics may be prescribed. Mononucleosis is a viral illness that is most commonly caused by Epstein–Barr virus or cytomegalovirus. The symptoms are generally malaise, fatigue, severe pharyngitis with posterior cervical lymphadenopathy, and fever.
Testing for mononucleosis can be complicated. A blood smear with >50% lymphocytes or >10% atypical lymphocytes can be used if other options are not available. This has an 87% positive predictive value and 93% negative predictive value [20]. Optimally, Epstein–Barr antibodies and nucleic antigen or an Epstein–Barr PCR should be checked. The heterophile antibody test, commonly referred to as a monospot, should not be used. It has poor sensitivity, especially within the first two weeks of symptoms, and can remain positive for up to a year after acute infection.
Treatment of mononucleosis is supportive and includes fluids, rest, analgesia, and fever control. Antibiotics are not indicated and, if inappropriately prescribed, can lead to the development of a macular erythematous, generalized rash. Steroids may be administered if there is concern for airway obstruction; otherwise, no significant benefit is conveyed by their use [21]. Patients should be advised to avoid contact sports for four to six weeks or until they are cleared by their primary care provider because of the risk of splenic rupture.
Gonococcal pharyngitis
Gonococcal pharyngitis must be considered in all sexually active patients, especially those who engage in oral sex. Patients may also have other sexually transmitted infection symptoms such as vaginal or urethral discharge. Nucleic acid amplification testing (NAAT) can be done on oropharyngeal swabs [22, 23]. NAAT is better than culture and is the preferred diagnostic test for gonococcal pharyngitis [24]. The decision to treat versus wait for confirmatory testing is based on the clinical suspicion. Treatment is ceftriaxone 500 mg intramuscularly (IM) once for patients <150 kg and 1 g IM for patients ≥150 kg [25].
Peritonsillar abscess
Peritonsillar abscesses (PTAs) are the most common cause of deep neck space infections [26]. PTAs form next to the palatine tonsils and are generally preceded by pharyngitis/tonsillitis. The cause is usually polymicrobial, the predominant organisms being GAS, Staphylococcus aureus (including MRSA), and respiratory anaerobes. Patients typically present with a sore throat, voice change, and trismus. On examination there is unilateral tonsillar enlargement, often with exudate, and contralateral displacement of the uvula. Rarely, bilateral PTAs do occur, making diagnosis challenging. Although uncommon, a PTA can lead to life‐threatening airway obstruction.
Imaging is not required to diagnose a PTA, although it may be necessary if there is diagnostic uncertainty. A CT scan with IV contrast or an ultrasound is the modality of choice. Ultrasound has the advantage of avoiding radiation exposure. It can also be used for live guidance if drainage is necessary.
Although it was previously believed that all PTAs require drainage, that has now been brought into question [27, 28]. Hemodynamically stable, well‐appearing patients without concern for airway compromise may be trialed with IV antibiotics, IV steroids, and IV fluids, then discharged with a course of oral antibiotics.
Either clindamycin 900 mg, ampicillin‐sulbactam 3 g, or piperacillin‐tazobactam 4.5 g can be used as a first‐dose IV agent. For patients with severe infections, vancomycin can be added, particularly if MRSA in the area has a high resistance to clindamycin. Dexamethasone 10 mg IV can help to reduce pain and swelling. Supportive care includes hydration, fever control, and analgesia.
Stable, well‐appearing patients with PTA who are able to tolerate oral fluids can be discharged with a course of amoxicillin‐clavulanate 875 mg orally twice a day or clindamycin 300 mg every 8 hours for 14 days.
Retropharyngeal abscess, epiglottitis, and Ludwig angina
Retropharyngeal abscess, epiglottitis, and Ludwig angina are deadly deep neck space infections that must be considered in patients with severe throat pain. Retropharyngeal abscess is much more common in children, but it can occur in adults. Epiglottitis was previously primarily a disease of children, but since the introduction of the Haemophilus influenza type b vaccine the most common patient now is an adult. Patients with Ludwig angina typically have difficulty swallowing because their tongue is displaced due to swelling of the floor of the mouth. Patients with these illnesses are usually ill appearing and may exhibit concerning symptoms such as dyspnea, inability to swallow secretions, resistance/inability to lay flat, painful neck movement, and/or head being held forward in the sniffing position. The presence of any of these findings portends a more serious infection. These diagnoses should also be considered when the severity of the throat pain does not correlate with the physical examination or if stridor is auscultated.
All of these conditions require emergent care due to a potentially unstable airway. Patients should be transported to the hospital by ambulance. While awaiting transport, leave the patient in a position of comfort and obtain IV access in adults. Consider deferring IV access in children due to the risk of respiratory distress induced by crying. The diagnosis is confirmed via CT scan (if the patient is stable enough to get the study) or in the operating room by direct visualization. Treatment involves parenteral antibiotics, steroids, surgical consultation, and admission.
KEY FACT | In the past epiglottitis was encountered more frequently in children, but adults have become the primary group with this disease.
Ear
Acute otitis media
Acute otitis media (AOM) is an infection of the middle ear that typically follows an upper respiratory infection. Patients are usually children who present with fever and ear pain or ear pulling. They may have decreased hearing on the affected side.
The patient will likely be febrile and otoscopy will show a moderately to severely bulging, erythematous, possibly opaque tympanic membrane (TM). If the patient complains of ear discharge, then a perforation may be seen. Pneumotoscopy will cause little or no movement of the TM.
AOM is difficult to differentiate from otitis media with effusion (OME). Both will present with ear pain and fullness, as well as a nonmobile TM, but OME is not infectious so patients will not exhibit signs of infection, such as fever or an erythematous TM. OME does not need treatment as it is a self‐limiting disease.
All AOM patients should receive symptom control. Acetaminophen and/or ibuprofen can be used for analgesia and for fever control. For children older than three years, three drops of aqueous lidocaine 2% can be instilled into the external auditory canal once, as long as there is no concern for TM perforation [29].
The major decision in the treatment of AOM is whether or not to prescribe antibiotics immediately versus allowing for a period of observation. A delayed prescription for antibiotics is often referred to as a “wait and see prescription” (WASP). This involves providing a prescription for the patient but asking that it only be filled after 48–72 hours if symptoms persist [30]. Treatment versus WASP guidelines is listed in Table 1.5 and antibiotic treatment options in Table 1.6.
Mastoiditis
Mastoiditis is a suppurative complication of AOM where the infection spreads into the mastoid air cells posterior to the ear. Patients present with signs and symptoms of AOM plus pain behind the ear. On examination the ear is typically abducted away from the skull, purulent otorrhea may be present, and the area behind the ear is erythematous and tender to palpation [31].
Table 1.5 Treatment considerations for acute otitis media.
Immediate antibiotics
Consider WASP
<6 months old
6–23 months of age with unilateral otitis media and without severe symptoms
a
6–23 months with bilateral AOM
Age ≥24 months with mild ear pain (unilateral or bilateral) and without severe symptoms
a
≥6 months old with severe symptoms
a
AOM, acute otitis media; WASP, wait and see prescription.
a Severe symptoms are defined as moderate–severe ear pain, pain >48 hours, fever ≥39 °C [30].
Table 1.6 Treatment options for acute otitis media.
Antibiotic
Population
Dose
Duration
Amoxicillin
Children
New infection
Recurrence >15 d since last antibiotic
45 mg/kg/dose PO q 12 h (max 1 g/dose)
Age <2 yr: 10 d Age 2–5 yr: 7 d Age >5 yr: 5 d All ages with severe symptoms: 10 d
Amoxicillin‐clavulanate
Adults
875 mg/125 mg PO q 12 h
5–7 d
Cefdinir
Mildly penicillin‐allergic child
7 mg/kg/dose PO q 12 h (max 300 mg/dose)
5–10 d
Cefdinir
Mildly penicillin‐allergic adult
600 mg PO q 24 h
5–10 d
Azithromycin
Severely penicillin‐allergic child
10 mg/kg PO (max 500 mg) qD × 1 d then 5 mg/kg PO (max 250 mg) qD on days 2–5
5 d
Azithromycin
Severely penicillin‐allergic adult
500 mg PO qD × 1 d then 250 mg PO qD days 2–5
5 d
Amoxicillin‐clavulanate
Immunosuppressed, recently hospitalized, antibiotics within 30 d, failed prior treatment, child
45 mg/kg PO q 12 h (max 1 g/dose)
10 d
Ceftriaxone
Recurrent infection <15 days, child
50 mg/kg IV q 24 h (max 1 g/dose)
3 d
IV, intravenously; PO, orally; q, every; qD, daily.
Any patient with concerns for AOM complications, such as mastoiditis or intracranial extension, should be referred to the ED for IV antibiotics and imaging.
KEY FACT | Patients with acute otitis media should not have cranial nerve abnormalities, mastoid tenderness, vertigo, nystagmus, ataxia, or meningismus. If these are present, the patient needs prompt referral to an emergency department for further care.
Tympanic membrane perforations
TM perforations can be due to AOM, blunt or penetrating trauma, barotrauma, blast injuries, or FBs. If the perforation is due to AOM then treat as per the AOM recommendations. If the perforation is from a retained FB, emergent referral to an ENT physician for removal is needed. Otherwise, most spontaneous TM perforations will heal spontaneously and do not require intervention.
If TM perforation is seen or suspected, do not irrigate the ear or perform pneumotoscopy. If the history provided is not consistent with a mechanism of TM perforation, then abuse should be suspected.
In the absence of infection, treatment focuses on pain management and keeping water out of the ear. This can be accomplished by placing a cotton ball coated with petroleum jelly into the external ear canal before showering or other exposure to water.
KEY FACT | Tympanic membrane perforation associated with severe hearing loss, vomiting, ataxia, nystagmus, vertigo, facial nerve abnormality, Battle sign, or racoon eyes requires emergent ENT evaluation.
Nose
Epistaxis
Epistaxis is a common patient presentation in the urgent care setting. It occurs more frequently in the winter months because of low humidity levels. Digital trauma, chemical irritants, and infections are common causes [32]. Most cases of epistaxis are self‐limited but severe bleeds can be life threatening. Bleeds emanate from two primary locations. Anterior bleeds (90%) occur because of bleeding from the anterior nasal septum, and posterior bleeds (10%) occur from vessels in the posterior nasopharynx. Due to the noncompressible location of these posterior vessels, posterior bleeds tend to be high volume and are much more dangerous than their anterior counterparts.
The first step in managing nonmassive epistaxis is to compress the bleeding vessels. This is accomplished by the provider or patient squeezing the soft tissue portion of the nose, inferior to the nasal bone, for 5–10 minutes without interruption. Effective compression is achieved when the patient's voice sounds different (“nasal” voice) because of decreased airflow through the nose. After compression has been applied, the posterior oropharynx must be examined to assess for any ongoing bleeding down the back of the throat. A clot may be present, but the presence of active bleeding may indicate a posterior bleed. Posterior bleeds require transportation to an ED.
Applying ice to the palate can reduce blood flow to the nasal mucosa and help achieve hemostasis [33]. Applying ice to the exterior nose or the neck is ineffective [34].
If hemostasis is not achieved by compression, then a topical vasoconstrictor and/or hemostatic agent should be applied to the nasal mucosa with an atomizer or by soaking a gauze/pledget in the desired solution. Vasoconstrictors include oxymetazoline 0.05%, phenylephrine 0.5%, and epinephrine 1 mg/ml solution. Tranexamic acid is a hemostatic agent that can also be atomized or applied via soaked gauze/pledget to the mucosa to reduce bleeding [35]. Consider mixing a topical anesthetic with these agents for patient comfort should additional interventions be needed. Lidocaine with epinephrine atomized or applied topically works as both a vasoconstrictor and an anesthetic.
After the topical medications are applied and/or the gauze/pledget is removed, examine the nasal mucosa to see if hemostasis is achieved or, if not, if the site of the bleeding can be visualized. If hemostasis is not achieved and the site of bleeding can be identified, cautery with silver nitrate can be attempted. This must be done under direct visualization. Circumferential cautery around the bleeding site prior to cauterizing the vessel itself is often effective [32]. If the bleeding is bilateral, do not cauterize both sides of the septum due to the risk of causing a septal perforation.
If the bleeding site cannot be seen or if bleeding continues despite these measures, the next step is to place a nasal packing. Again, the posterior oropharynx should be assessed during and after each of these steps. If there is concern for a posterior bleed, then transport the patient to the ED.
Anterior packing can be absorbable or nonabsorbable. Absorbable packing is usually hemostatic material that will dissolve over several days. Both are effective and the choice of packing is usually determined by what is readily available. Absorbable packing is preferred in patients who are at increased risk for rebleeding when the packing is removed [36]. This included patients with bleeding disorders and those on anticoagulant or antiplatelet medications. Packing should be placed parallel to the bottom of the nasal cavity and must be secured to the face to avoid posterior displacement, which can lead to aspiration and airway occlusion.
If the patient is hypertensive and hemostasis can be achieved, there is no indication for acute lowering of the blood pressure with IV medications. Rather, gradual lowering can be achieved with oral agents. Routine labs and imaging are not necessary for uncomplicated epistaxis. If a patient is on an anticoagulant with a measurable level, checking the level can be considered.
Patients in whom bleeding is controlled and are otherwise stable can be discharged. If a nonabsorbable nasal packing is in place, then follow‐up should be arranged to have it discontinued in three days. Antibiotics are not necessary if the packing will be removed within 72 hours [37]. Absorbable nasal packing will disintegrate on its own and antibiotics are not necessary. All discharged patients should be advised to avoid nose blowing to avoid disrupting a hemostatic clot.
KEY FACT | All patients with posterior bleeds (bleeding down the posterior oropharynx despite nasal soft tissue compression) are at risk for high‐volume blood loss and must be referred to an ED.
Foreign bodies
FBs of the ears and nose will bring many children, and a few adults, to urgent care centers. The typical presentation of a nasal FB is a child with unilateral nasal discharge without other upper respiratory symptoms. The typical presentation of an ear FB is a child presenting with unilateral ear pain without other signs of illness. Alternatively, a patient may present with a caregiver who saw the patient insert an FB or visualized the FB in the ear or nose.
General principles of FB treatment are as follows. If there is any concern for airway compromise (stridor, hypoxia, or respiratory distress) the patient requires immediate ambulance transport to an ED. Regardless of location, button batteries, live objects, and sharp FBs must be removed as quickly as possible. Button batteries can cause tissue necrosis within 15 minutes of exposure [38]. Uncomplicated FBs should not cause systemic illness or focal neurologic findings, including facial nerve palsies or cerebellar signs. When one FB is found, be sure to check the other head orifices for additional objects.
Complications of ear FBs include TM perforation with possible ossicle disruption leading to vertigo, ataxia and nystagmus, or otitis media. Complications of nasal FBs include aspiration, epistaxis, periorbital cellulitis, and meningitis. If any of the listed complications are present, the patient requires referral to an ED.
There are several removal techniques for nose and ear FBs. Before attempting removal, consider applying topical local anesthetic to improve patient comfort. For nose FBs, consider applying a topical vasoconstrictor (phenylephrine or oxymetazoline) to reduce swelling and facilitate removal. Live FBs should be killed prior to attempting removal. This can be done by instilling mineral oil, nonviscous lidocaine, or ethanol onto the object [39]. Ticks should be submerged in acetone, ethanol, or isopropyl alcohol [40]. Patients should be positioned during removal attempts such that if an object becomes dislodged it will fall out of the orifice.
Removal with alligator forceps is best when the FB can be easily visualized, does not have a smooth surface, and is nonfriable. Friable FBs may break into pieces when grasped. An alternative technique involves the use of topical adhesive. Place a small amount of topical adhesive onto the nonpadded end of a swab then bring that swab into contact with the FB for 30–60 seconds. The goal is then to remove the swab and the FB together. With this technique, the operator must take care to not come in contact with anything other than the FB. Another technique involves using a suction catheter with a small end (e.g. Frazier tip) to directly suck out the FB. This works best for smooth, round FBs. With this technique the operator must use low, continuous suction and be careful not to push the FB further into the orifice.
For nasal FBs, an initial attempt can be made at removal using a “positive pressure technique.” This is done by applying positive pressure through the mouth and having the only route of exit for the pressure be through the affected nostril. So if the FB is in the right nare, positive pressure is applied through the mouth while the left nostril is occluded. Positive pressure can be applied by the caregiver by using their mouth to puff air into the patient (sometimes referred to as the “parent's kiss”) or through the use of a bag valve mask over the patient's mouth only.
For ear FBs, irrigation can also be attempted. This technique should not be used if the FB will expand when wet or if it is a button battery. Attempt to pass an angiocath past the FB then gently irrigate with body‐temperature water.
Magnets can be used to remove metallic FBs, including magnets. A strong magnet (such as a pacemaker magnet) is applied to the end of a metallic instrument (e.g. hemostat or forceps) and then the instrument is brought into contact with the FB. The goal is to have the FB stick to the end of the instrument so that the two can be removed together.
Pearls for improving patient outcomes
Patients with corneal abrasions, ulcers, and removed corneal foreign bodies are all treated with antibiotics and should see an ophthalmologist within 24 hours.
Contact lens wearers with corneal abrasions or patients with corneal ulcers (regardless of contact lens use) require antipseudomonal antibiotic coverage and should be advised to refrain from wearing their contact lenses until they are cleared to do so by an ophthalmologist.
Red flag warning signs for patients who present with a sore throat include difficulty breathing, inability to swallow secretions, resistance/inability to lie flat, painful neck range of motion, and/or head held forward in the sniffing position.
The decision to prescribe antibiotics for possible streptococcal pharyngitis should be based on clinical suspicion, the modified Centor score, and testing.
The need to prescribe antibiotics immediately versus providing a delayed prescription for acute otitis media is based on the patient's age and symptoms.
Patients with persistent epistaxis or ongoing bleeding in the posterior oropharynx from epistaxis require immediate transport to an emergency department.
Button batteries and sharp object foreign bodies require emergent removal.
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